New Club Members - Application for Temporary Exemption
Surname: ____________________________________________ Given Names: ____________________________________________________
Sex: Male o Female o
Residential Address:________________________________________________________________________________ Postcode:____________
Postal Address:________________________________________________________________________________________________________
Telephone: ( )___________________________ Drivers Licence No.: _________________________Date of Birth:__________________
Club Name:_Cecil Park Clay Target Club___________________________________________________________
Club Approval No:_40575883Q ________________________________________________________________________
Mailing Address:__P.O BOX
260
Telephone: (02) 9826 1399_____________________________ Facsimile: ( 02 ) 9826 1933__ _________________
If you answer yes to any of the questions below, please provide full information with this application.
1. Do you hold a current firearms licence? (please specify category) oA oB oH oNO
2. Have you previously been granted a temporary exemption? (please specify category) oA oB oH oNO
3. Have you, in New South Wales or elsewhere, been refused or prohibited from holding a firearms licence or had a
firearms licence suspended, cancelled or revoked? oYES oNO
4.
Have you, in
5. Have you, in
been fined for an offence in respect of (a) Firearms or (b) Any other offence other than a minor motor traffic? oYES oNO
6. Have you, in
(a) Family Law or Domestic Violence Order, or
(b) Apprehended Violence Order (other than an order that has been revoked)? oYES oNO
7. Have you, in
(a) Alcoholism (b) Drug Dependence (c) A Mental or Nervous Disorder (d) Attempted Suicide or Self Harm oYES oNO
8. Do you suffer from any physical or mental disability that may affect you in the control of firearms? oYES oNO
9. Is your mode of living or domestic circumstances such that you are unable to personally exercise continuous and
responsible control over firearms? (eg. Do you reside with a person who has been refused or had a firearms licence
revoked, is subject to an apprehended violence order, or suffers from a mental illness or disorder) oYES oNO
10. Have you ever changed your name? (please specify previous name) . . oYES oNO
11. Are you currently subject to a Good Behaviour Bond? oYES oNO
I authorise (print name of club) ... . Club, to request the NSW Police to carry out any necessary checks to approve my having access to o A o B o H (TICK BOX) firearms for target shooting and to notify the Club of approval or refusal.
I am aware this application will be subject to all necessary checks as may be conducted by Officers of the NSW Police and that this application may be refused for any reason the Commissioner of Police (NSW) deems fit.
Signature of Applicant: Date: ..
Declaration by Parent or Legal Guardian to Identify and Give Consent for Applicant to Participate.
I, (full name) .. of: (address) ... ...
Date of Birth: ./.. ./ .. hereby declare I am the Parent/ Legal Guardian (cross out which is not applicable). I confirm identification of the applicant and give my consent for him/ her to participate in approved target shooting activities conducted by the above named club.
Witness: (full name) .. of: (address) ... ...
CERTIFICATION of CLUB MEMBERSHIP. I hereby certify the applicant whose details and signature appear above is a new member of the above named club and the two documents below identify the applicant or if applicant is a minor identify the parent/ legal guardian.
First Document Details : .. Second Document Details: . .
Full Name of Club Official: . . Position Held: .. ....
Signature of Club Official: .. Date: ..
Firearms Registry Contributing to Community Safety
v The application form overleaf should be completed in black ink, in legible block letters. Failure to do so may result in your application being delayed.
v It is important that you understand the questions and answer them fully and honestly. If you do not understand any of the questions, seek assistance from the Club Secretary. It is an offence, under the provisions of section 70 of the Firearms Act 1996, to provide false or misleading information.
v An approval granted under this clause exempts you from the requirement under the Firearms Act, 1996 to be authorised by a licence to possess or use a firearm (other than a prohibited firearm) but only:
Ψ While participating in target shooting at an approved range, and
Ψ While under the supervision of a club range officer.
v Temporary exemption commences on the first occasion you participate in target shooting at an approved range (as a temporary or probationary member of an approved club) and extends for up to 3 months or until you are issued with a firearms licence (whichever occurs first).
v Generally, a club member can only apply for temporary exemption once in a lifetime; however, the Commissioner may consider further approvals in respect of a different firearm type.
Return Fax (02) 6670 8550